title: Nursing malpractice: the importance of documentation, or saved by the pen!
abstract: Documentation is an elemental to nursing as wound care and vital sign assessment. This article examines the reasons and techniques for accurate and complete documentation in a medical record. Several examples of nursing malpractice involving improper documentation are described. Abbreviations, flow sheets, incident reports, late entries, errors and content are included in the discussion presented.
authors.forename: M
authors.initials: M
authors.lastname: Gruber
authors.forename: J M
authors.initials: JM
authors.lastname: Gruber
mesh_terms: D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D009730:Nursing Assessment / Q000592:standards*; D009737:Nursing Records / Q000592:standards*; D012308:Risk Management; D016312:Treatment Refusal